2000 / 6月
Chang Chiung-fang /tr. by Robert Taylor
On 24 May 2000 the Palliative Care Statute received its third and final reading in the Legislative Yuan. Henceforth, it is no longer illegal to allow a person to die a "natural death." It is estimated that in Taiwan, some 10,000 patients a year will be spared the pain of futile efforts to revive them as they die, and will be able to die with dignity. "Palliative care," or "natural death," as it is often referred to, means that in accordance with a patient's expressed free will, medical staff will refrain from using cardiopulmonary resuscitation (CPR), artificial respirators, heart stimulants and other invasive medical technologies to prolong the dying process of patients with untreatable conditions.
Natural death is not the same as euthanasia. The greatest difference is that euthanasia deliberately ends a patient's life earlier than it would otherwise have ended; natural death may also "shorten" a person's life, but merely by refraining from using active, invasive resuscitation procedures, thereby allowing a terminally ill patient to die naturally.
In the past, the Medical Care Law required that: "Where a hospital or clinic encounters a patient in a dangerous condition, it shall, in accordance with its facilities, provide emergency treatment or take all such measures as are necessary, without undue delay."
The effect of this statutory requirement has been that even when doctors know that a patient will not survive, and that the patient does not wish their death to be prolonged by being painfully kept alive by machines, they still have to give the patient emergency treatment, or they may face prosecution for negligent homicide after a complaint by the patient's family. Palliative care has been practiced for many years, but in the past it was always done illegally, and even where hospitals drew up their own consent forms for patients to refuse CPR, such documents had no legal validity.
Under the new legislation, palliative treatment is only available to terminally ill patients, and for a patient to be defined as terminally ill, two physicians must diagnose that their condition is "incurable and there is medical evidence that it will inevitably progress to death within a short time."
Of course, a precondition for palliative care is a consent form signed by the patient. A patient who has signed such a consent form may retract it at any time. If a patient's consciousness is impaired and they are unable to clearly express their wishes, a consent form may be signed by close relatives instead.
To avoid people being denied the right to medical self-determination because they are unable to express their will, anyone over 20 years of age and of full capacity may make an "advance declaration" of their wishes (also known as a "living will"), and may appoint a medical representative who is empowered to sign a consent form on their behalf if they are unable to express themselves.
In 1976, the state of California enacted the Natural Death Act, America's first right-to-die statute, and many other advanced countries also have similar laws. Chen Liang-chuan, executive director of the Catholic Sanipax Medico-Social Educational Foundation, says that Taiwan has started late on the road to promoting palliative care, but the legislation is nonetheless pioneering in Asia.
The enactment of the Palliative Care Statute has been warmly welcomed by front-line medical staff, as well as by people who have long been campaigning for palliative care to be legalized.
Chao Ko-shih, an associate professor in the nursing department at National Cheng Kung University's medical school, says: "Death can be as beautiful as an autumn leaf, and every human being has a right to a good life and a good death." Legislative Yuan member Chiang Chi-wen, one of the sponsors of the legislation, says that it brings four benefits: patients gain the right to self-determination regarding their own medical care, family members can accompany dying patients in peace, the medical professions can provide the care which gives the best quality of life, and the government is taking a great step forward in reforming the way it handles citizens' death.
However, some legislators have expressed concern that the new law could be abused to deliberately cause death, and may lead to human life being too easily disrespected. Li Ming-liang, director of the Department of Health, says that the philosophy behind palliative care is different from the traditional attitude of trying to prolong life at all costs, and in drawing up the enforcement rules for the Palliative Care Statute during the next three months, the DOH will seek to prevent inappropriate implementation leading to infringement of patients' rights.
Now that the statute has been enacted, accompanying measures will also be introduced. From July of this year, the National Health Insurance Bureau plans to include palliative care in the types of care paid for by National Health Insurance, to increase hospitals' willingness to provide palliative care beds. The bureau hopes that the number of such beds can be quickly increased from the present 249 to 1,200, which would be in line with needs.
A dignified death without pain is something many people fervently wish for. The enactment of the Palliative Care Statute should give patients greater choice in the terminal care they receive. Pictured here is the palliative care ward at Taipei's Mackay Memorial Hospital. (photo by Hsueh Chi-kuang)